MEDICARE: TYRA ALYSSA DAVIS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PAT9117863	FL

General Provider Information

NPI Number	:	1629758727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYRA ALYSSA DAVIS PA

Provider Business Mailing Address
First Line	:	1361 13TH AVE S
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3233
Country	:	US
Telephone Number	:	904-249-2580
Fax Number	:

Provider Business Practice Location Address
First Line	:	6675 CORPORATE CENTER PKWY
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-8079
Country	:	US
Telephone Number	:	904-424-5891
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2023
Last Update Date	:	09/15/2023

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